Youth Services Family Information/Waitlist Form

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Livermore Area Recreation and Park District

Youth Services Division

71 Trevarno Road
Livermore CA 94550
Phone: 925-960-2480
Email: youthservices@larpd.org

Youth Services Family Information/Waitlist Form

Extended Student Services (ESS) Elementary School

PAL Middle School

*Primary Family Email Address

Mother's Name

Mother's Email Address (If different from the Primary email address)

Mother's Primary Phone

Mother's Secondary Phone

Father's Name

Father's Email Address (If different from the Primary email address)

Father's Primary Phone

Father's Secondary Phone

Address

City

State/Province

Zip Code

Preferred Language

Please List All Children

Child #1 Name

Child #1 Birth Date

Child #1 Year Starting

Child #1 Grade

Child #1 Home School

Child #2 Name

Child #2 Birth Date

Child #2 Year Starting

Child #2 Grade

Child #2 Home School

Child #3 Name

Child #3 Birth Date

Child #3 Year Starting

Child #3 Grade

Child #3 Home School

Child #4 Name

Child #4 Birth Date

Child #4 Year Starting

Child #4 Grade

Child #4 Home School

Is your child already attending an LVJUSD school?

Yes

Do you think you qualify for subsidy assistance?

Yes

Tuition assistance is based on a sliding scale.

If you feel you may be eligible for tuition assistance, please indicate your total gross family monthly income

If you feel you may be eligible for tuition assistance, please indicate you family size: #Adults/#Children

Comments or Questions Your application will be dated upon receipt and you will be contacted when there is an opening at your home school site or the school your student is currently enrolled in.